Current through Register Vol. 24-18, September 15, 2024
This section applies to employer groups for the public
employees benefits board (PEBB) program as defined in WAC
182-08-015. An employer group may
apply to obtain PEBB insurance coverage through a contract with the health care
authority (HCA).
(1) Employer groups
with less than 500 employees must apply at least 60 days before the requested
coverage effective date. Employer groups with 500 or more employees but with
less than 5,000 employees must apply at least 90 days before the requested
effective date.
Employer groups with 5,000 or more employees must apply at
least 120 days before the requested coverage effective date.
To apply, employer groups must submit the documents and
information described in subsection (2) of this section to the PEBB program as
follows:
(a) Counties, municipalities,
political subdivisions, and tribal governments with fewer than 5,000 employees
are required to provide the documents and information described in subsection
(2)(a) through (f) of this section;
(b) Counties, municipalities, political
subdivisions, and tribal governments with 5,000 or more employees will have
their application approved or denied through the evaluation criteria described
in WAC 182-08-240 and are required to
provide the documents and information described in subsection (2)(a) through
(d), (f), and (g) of this section; and
(c) All employee organizations representing
state civil services employees and the Washington health benefit exchange,
regardless of the number of employees, will have their application approved or
denied through the evaluation criteria described in WAC
182-08-240 and are required to
provide the documents and information described in subsection (2)(a) through
(d), (f), and (g) of this section.
(2) Documents and information required with
application:
(a) A letter of application that
includes the information described in (a)(i) through (iv) of this subsection:
(i) A reference to the group's authorizing
statute;
(ii) A description of the
organizational structure of the group and a description of the employee
bargaining unit or group of nonrepresented employees for which the group is
applying;
(iii) Tax identification
number; and
(iv) A statement of
whether the group is applying to obtain only medical or all available PEBB
insurance coverages.
(b)
A resolution from the group's governing body authorizing the purchase of PEBB
insurance coverage.
(c) A signed
governmental function attestation document that attests to the fact that
employees for whom the group is applying are governmental employees whose
services are substantially all in the performance of essential governmental
functions.
(d) A member level
census file for all of the employees for whom the group is applying. The file
must be provided in the format required by the authority and contain the
following demographic data, by member, with each member classified as employee,
spouse or state registered domestic partner, or child:
(i) Employee ID (any identifier which
uniquely identifies the employee; for dependents the employee's unique
identifier must be used);
(ii)
Age;
(iii) Birth sex;
(iv) First three digits of the member's zip
code based on residence;
(v)
Indicator of whether the employee is active or retired, if the group is
requesting to include retirees; and
(vi) Indicator of whether the member is
enrolled in coverage.
(e)
Historical claims and cost information that include the following:
(i) Large claims history for 24 months by
quarter that excludes the most recent three months;
(ii) Ongoing large claims management report
for the most recent quarter provided in the large claims history;
(iii) Summary of historical plan costs;
and
(iv) The director or the
director's designee may make an exception to the claims and cost information
requirements based on the size of the group, except that the current health
plan does not have a case management program, then the primary diagnosis code
designated by the authority must be reported for each large claimant. If the
code indicates a condition which is expected to continue into the next quarter,
the claim is counted as an ongoing large claim. If historical claims and cost
information as described in (e)(i) through (iii) of this subsection are
unavailable, the director or the director's designee may make an exception to
allow all of the following alternative requirements:
* A letter from their carrier indicating they will not or
cannot provide claims data.
* Provide information about the health plan most employees
are enrolled in by completing the actuarial calculator authorized by the PEBB
program.
* Current premiums for the health plan.
(f) If the application is for a
subset of the group's employees (e.g., bargaining unit), the group must provide
a member level census file of all employees eligible under their current health
plan who are not included on the member level census file in (d) of this
subsection. This includes retired employees participating under the group's
current health plan. The file must include the same demographic data by
member.
(g) Employer groups
described in subsection (1) (b) and (c) of this section must submit to an
actuarial evaluation of the group provided by an actuary designated by the PEBB
program. The group must pay for the cost of the evaluation. This cost is
nonrefundable. A group that is approved will not have to pay for an additional
actuarial evaluation if it applies to add another bargaining unit within two
years of the evaluation. Employer groups of this size must provide the
following:
(i) Large claims history for 24
months, by quarter that excludes the most recent three months;
(ii) Ongoing large claims management report
for the most recent quarter provided in the large claims history;
(iii) Executive summary of
benefits;
(iv) Summary of benefits
and certificate of coverage; and
(v) Summary of historical plan costs.
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Exception:
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If the current health plan does not have a case
management program then the primary diagnosis code designated by the authority
must be reported for each large claimant. If the code indicates a condition
which is expected to continue into the next quarter, the claim is counted as an
ongoing large claim.
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(3) The authority may automatically deny a
group application if the group fails to provide the required information and
documents described in this section.
Statutory
Authority:
RCW
41.05.160 and
2012 2nd sp.s. c
3 . WSR 13-22-019 (Admin. 2013-01),
§182-08-235, filed 10/28/13, effective 1/1/14. Statutory Authority:
RCW
41.05.160. WSR 12-20-022 (Order 2012-01),
§182-08-235, filed 9/25/12, effective 11/1/12. WSR 13-21-033,
§182-08-235, filed 10/9/2013, effective
11/9/2013
